Gastroenterology Coding Alert

Question: We received a denial for a screening colonoscopy (G0121) for a Medicare patient who is not at high risk. What are the requirements that support this procedure, the appropriate code to use, and the screening frequency that is allowed?
       

Iowa Subscriber

Answer: For Medicare to consider a patient "not at high risk," the patient's medical history must meet none of the following requirements:
   close family member (parent, sibling, or child) diagnosed with colorectal cancer
   family history of close family member with adenomatous colon polyps
   family history of hereditary nonpolyposis colorectal cancer
   personal history of colon polyps
   personal history of colorectal cancer
   personal history of irritable bowel syndrome, Crohn's colitis, or ulcerative colitis.  Effective July 1, 2001, Medicare began to allow screening colonoscopies once every 10 years for individuals not at high risk for colorectal cancer. Also, for an individual who is not at high risk for colorectal cancer but who has undergone a screening flexible sigmoidoscopy paid for by Medicare within the past four years, this new law provides that Medicare will pay for a screening colonoscopy only after at least 47 months have passed following the month in which the last flexible sigmoidoscopy was performed.
 
Use HCPCS code G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) for this screening service.
 
Medicare says that your office cannot also bill for a preprocedure visit to determine the suitability of the patient for the colonoscopy. E/M services, including consultations, are not separately payable. The fee schedule, however, is structured to include payment for the preprocedure visit and services.
 
Use G0121 for this lower-risk screening colonoscopy. You should continue using the existing code (G0105, Colorectal cancer screening; colonoscopy on individual at high risk) for screening colonoscopies done for individuals at high risk.
 
Both G0121 and G0105 are paid at the same rate as diagnostic colonoscopy 45378 (Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]).